For the fourth time since 2018, Kerala is confronting the deadly virus Nipah. The zoonotic disease is revisiting the North Kerala district of Kozhikode for the third time since then.
The lessons from the previous bouts of the infection, coupled with two consecutive years facing the Covid-19 pandemic in 2020 and 2021, have helped Kerala take the virus head-on in its fourth foray into Kozhikode villages.
The outbreak of 2018, which claimed 17 lives out of 18 confirmed cases, had caught the state health department off-guard. The government had no past experience of handling a disease with such a high fatality rate. At the time, the disease was identified only after the virus had already started spreading among human, and claimed a few victims.
What the state then followed was the protocol for Ebola virus disease (EVD), which had been reported mainly in sub-Saharan Africa. Social distancing, contact tracing and isolation became new concepts to Kerala society. Images of health workers in PPE kits filled the TV screens for the first time.
Still, during the first outbreak, the health department had only limited knowledge to fall back on to fight the alien virus. But a co-ordinated effort was launched for the virus’s containment. Apart from the health department, the revenue district administration took up the lead in coordinating with various stakeholders. Route maps of confirmed cases were published to identify contacts and make people self-report. All contacts were put under home quarantine, then unprecedented in Kerala.
At one point of time, 3000 persons had been under quarantine. A call centre was launched in Kozhikode to give psychological support for all those under quarantine. Isolation wards were opened at the government medical college hospital, which took care of all patients and suspected cases. Several ad-hoc committees were formed. Slowly a procedure was in the making at the war-room of Kozhikode, wards of the medical college hospital and fields of the affected villages.
In early June, 2019, the health department issued a short Nipah virus infection control guideline. Later in that month, when a case was reported in Ernakulam, the health department, with the support of various other departments, streamlined surveillance activities, contact tracing, quarantine, isolation, and treatment. A medical board, treatment protocol, use of monoclonal antibody protocol and point of care testing were framed.
It was the back-to-back confirmation of Nipah in 2018 and 2019 (then one case in Ernakulam) that forced the health department to work out a systematic approach to deal with any future outbreaks.
Thus, even while tackling the virus in 2019, during its second revisit to Kerala, the health department was already engaged in building structures and processes. A resource group of senior doctors held several brainstorming meetings for preparing guidelines, capacity building, and co-ordinated fight against the Nipah. At one stage, WHO representatives were also involved in protocol preparation and mock drills were held. The guidelines covered diagnosis, surveillance, treatment and sample collection. These guidelines have been revised twice since they first came up and have been very valuable.
In fact, on 30 January, 2020, when Kerala reported the country’s first coronavirus case in Thrissur, the experience of handling Nipah for the past two years held Kerala in good stead. From the day one of coronavirus, the state could roll out its Nipah guidelines, including contact tracking, publication of route map, isolation, treatment and containment at grassroots level.
In 2020, the state did not report any Nipah case, but the protocol of 2019 was updated and sent across the system. The protocol was again updated in 2021, making it more comprehensive on all aspects including treatment algorithm.
In September 2021, when a 12-year-old boy died in Kozhikode due to Nipah, the state was in the trenches in its battle against a second wave of the Covid-19 pandemic. But this helped dealing with Nipah as the society at large has been used to quarantining and isolation, and there was a higher degree of compliance among the public with regard to wearing masks.
That year Nipah was confined to a single case as health workers and society were almost insulted due to covid-19 protocol.
In 2018, the health department could diagnose people with the Nipah virus only after a few victims died. The state did not have the lab facilities to confirm Nipah. A private hospital in Kozhikode, where a few first cases were treated, sent samples to Manipal Centre for Virus Research (MCVR), which was first to confirm Nipah in Kozhikode. Then it was re-confirmed by the NIV Pune as per the protocol.
During the outbreak of 2019, a POC micro-PCR assay for Nipah detection and ELISA testing facility was started at the govt medical college in Kochi with technical support from NIV, Pune. Since then, government labs have been upgraded in Kerala mainly in the wake of covid-19.
In 2023, Nipah was detected at the biosafety level-2 lab in Kozhikode, but final confirmation came from NIV Pune which has biosafety level-4 lab. In Kozhikode, the government lab could detect the virus in six hours. At present, the state has another similar facility at
(With inputs from agencies)